Chiara Viganò

Assessing the activity of perianal Crohn's disease: Comparison of clinical indices and computer-assisted anal ultrasound

Background: Assessing perianal disease activity is important for the treatment and prognosis of Crohns disease (CD) patients, but the diagnostic accuracy of the activity indices has not yet been established. The aim of this study was to determine the accuracy and agreement of the Fistula Drainage Assessment (FDA), Perianal Disease Activity Index (PDAI), and computer‐assisted anal ultrasound imaging (AUS). Methods: Sixty‐two consecutive patients with CD and perianal fistulae underwent clinical, FDA, PDAI, and AUS evaluation. Perianal disease was considered active in the presence of visible fistula drainage and/or signs of local inflammation (induration and pain at digital compression) upon clinical examination. The AUS images were analyzed by calculating the mean gray‐scale tone of the lesion. The PDAI and gray‐scale tone values discriminating active and inactive perianal disease were defined using receiver operating characteristics statistics. Results: Perianal disease was active in 46 patients. The accuracy of the FDA was 87% (confidence interval [CI]: 76%–94%). A PDAI of >4 and a mean gray‐scale tone value of 117 maximized sensitivity and specificity; their diagnostic accuracy was, respectively, 87% (CI: 76%–94%) and 81% (CI: 69%–90%). The agreement of the 3 evaluations was fair to moderate. The addition of AUS to the PDAI or FDA increased their diagnostic accuracy to respectively 95% and 98%. Conclusions: The diagnostic accuracy of the FDA, PDAI, and computer‐assisted AUS imaging was good in assessing perianal disease activity in patients with CD. The agreement between the techniques was fair to moderate. Overall accuracy can be increased by combining the FDA or PDAI with AUS.

Computer-assisted evaluation of perianal fistula activity by means of anal ultrasound in patients with Crohn's disease

OBJECTIVES:Assessment of the activity of perianal fistulas may be of clinical relevance in patients with Crohns disease. Fistula activity is currently evaluated by means of magnetic resonance imaging; anal ultrasound can also be used, but its diagnostic performance in this setting remains to be defined. Our aims were to evaluate the agreement between clinical examination, magnetic resonance imaging, and anal ultrasound in assessing perianal fistula activity, and to apply computerized analysis to improve the assessment of ultrasound images.METHODS:Thirty-one consecutive patients with Crohns perianal fistulas underwent clinical examination, and magnetic resonance and anal ultrasound imaging. Active fistulas were defined as the presence of active drainage or signs of local inflammation on clinical examination, and the definition was confirmed by surgical examination. Activity was assessed on the basis of T2 hyperintensity on magnetic resonance imaging and the degree of hypoechogenicity on anal ultrasound; the anal ultrasound images were also analyzed using dedicated computer image-analysis software.RESULTS:Twenty-five patients had an active fistula at clinical examination. The agreement between clinical examination and magnetic resonance imaging was good (k-value = 0.739), whereas that with anal ultrasound was only fair (k-value = 0.266–0.294); computer-assisted analysis of the anal ultrasound images improved the agreement from fair to good (k-value = 0.608–0.670).CONCLUSIONS:Anal ultrasound can be used to assess fistula track activity in patients with Crohns disease. The diagnostic performance of the technique can be improved to values comparable with those of magnetic resonance imaging by using a computer-assisted evaluation of the anal ultrasound images.

Incidence and clinical outcomes of intersphincteric abscesses diagnosed by anal ultrasonography in patients with crohn's disease

Background: Intersphincteric abscesses have been reported as uncommon manifestations of perianal Crohns disease (CD) in surgical series, and may be diagnosed earlier by means of anal ultrasonography. The aim of this study was to evaluate the incidence and outcomes of intersphincteric abscess in a prospective cohort of patients with CD referred for perianal symptoms. Methods: Of the 420 patients with CD attending our outpatient clinic over a period of 5 years, 55 (31 males, mean age 38 ± 13 years) underwent anal ultrasonography because of newly developed symptoms suggesting perianal disease; a clinical evaluation and perianal examination was performed on the same day. Results: An intersphincteric abscess was diagnosed in 23 (42%) of the 55 patients with perianal symptoms, for a total cumulative 5‐year incidence of 5% (95% confidence interval [CI]: 3%–7%). During a median follow‐up period of 23 months (range 6–53), four of these patients required surgery, four developed a perianal fistula or small ischiorectal abscess not requiring surgery, and 15 experienced a benign course. The patients with a benign course had a longer duration of CD at the time of onset of the perianal symptoms. Conclusions: Intersphincteric abscesses frequently cause perianal symptoms in patients with CD, and their clinical outcomes vary from rapidly progressive inflammation to a benign self‐limiting course. The favorable outcome observed in some patients supports a first‐line conservative approach to the condition. (Inflamm Bowel Dis 2011;)

The problem of adherence to therapy in ulcerative colitis and the potential utility of multi-matrix system (MMX) technology

ABSTRACT Introduction: Ulcerative colitis (uc) is a chronic condition and for the vast majority of patients, life-long treatment is required. low adherence to therapy is an emerging issue. since low adherence is associated with poor clinical outcomes and increased costs, it is becoming crucial to identify strategies in order to improve it. Areas covered: We performed literature searches in PubMed using the terms ‘adherence’, ‘mesalamine’, ‘budesonide MMX’, ‘MMX technology’ in combination with ‘ulcerative colitis’. Firstly, we present the key-concepts of therapy for UC and discuss the problem of the adherence and how to measure it. Then, we provide data on the extent of the problem and the causes and consequences from clinical and economic point of views. Finally, we focus on treatment-related variables associated with non-adherence and treatment-related strategies to improve adherence, paying particular attention to Multi Matrix system (MMX) technology applied to mesalazine and budesonide. Expert commentary: The pharmaceutical industry and scientific community are making efforts to simplify treatments for UC. MMX technology, which allows a reduction in the number of pills to be taken and daily administrations, may facilitate adherence to treatment and carry further clinical benefits.

Adalimumab is safe and effective in re-inducing clinical remission after post-surgical relapse of Crohn's disease: A case report

Abstract We present the case of a 36-year-old patient with ileo-colonic stricturing Crohns disease that recurred after surgery, did not respond to maximal medical therapy and was only partially responsive to treatment with adalimumab administered subcutaneously. The patient underwent surgery following an episode of intestinal obstruction, revealing chronic, adhesive peritonitis, with the intestinal loops fixed strongly together, and a fibrotic stricture of the pre-anastomotic ileum. The numerous adhesions were carefully separated and the stenotic tract of ileum was resected. Following the resection the patient had an early clinical relapse, which was documented by abdominal ultrasound. The patient was, therefore, treated again with adalimumab: the new cycle of treatment achieved clinical and ultrasonographic remission of the disease. Despite the previous treatment, no side-effects occurred.

Granulocyte-Monocyte Apheresis in Steroid-Dependent, Azathioprine-Intolerant/Resistant Moderate Ulcerative Colitis: A Prospective Multicenter Study

Background Granulocyte-monocyte apheresis has been proposed for the treatment of ulcerative colitis, although it is limited by costs and variability of results. Aim To assess effectiveness of granulocyte-monocyte apheresis in patients with steroid-dependent, azathioprine-intolerant/resistant moderate ulcerative colitis. Methods Consecutive patients fulfilling inclusion criteria were prospectively enrolled, treated by apheresis, and followed up for 12 months. The primary end point of the study was steroid-free clinical remission at 12 months, with no need for biologic therapy or surgery. Results From January to December 2013, 33 patients were enrolled. After one year of follow-up, 12 (36%) patients had clinical remission, were steroid-free, and had no need for biological therapy or surgery; 3 (9%) cases showed a clinical response (but not clinical remission). Moreover, 12 (36%) patients required biologic therapy, 4 (12%) underwent colectomy, and in the other 2 (6%) a reduction, but not withdrawal, of steroid dose was achieved. Conclusions Our study shows that a standard course of granulocyte-monocyte apheresis is associated with a 36% steroid-free clinical remission in patients with steroid-dependent, azathioprine-intolerant or resistant moderate ulcerative colitis. Apheresis might represent an alternative to biologic therapy or surgery in this specific subgroup of patients. This trial is registered with Clinicaltrial.gov NCT03189888.